All Reports

The Director takes appropriate actions so leaders update the facility’s policy for communicating test results to include how providers communicate life-changing results to patients at high risk for suicide, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process to communicate test results, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate action so staff update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe staff members’ roles in the process of communicating test results to providers and patients, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate action so staff conduct a risk assessment to identify areas that need temperature and humidity monitoring and implement changes accordingly to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action so staff secure liquid nitrogen tanks, maintain unobstructed access to exits, conduct a risk assessment on safe liquid nitrogen storage options to increase safety, and implement changes accordingly to align with the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code NFPA 55, Health Care Facilities Code NFPA 99, and Code of Federal Regulations title 29, section 1926.34.

The Director takes appropriate action so staff improve processes to prevent repeat environment of care findings as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions throughout the facility to support patient and visitor navigation, in alignment with VA Integrated Wayfinding & Recommended Technologies.

The Director takes appropriate steps to repair exterior walkways and mitigate identified safety hazards, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions to improve the cleanliness, safety, and maintenance of patient care areas, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director implements measures to keep exit pathways free of obstructions, as required by the Joint Commission Standards Manual, Life Safety, 02.01.20.

The Director requires the Comprehensive Environment of Care Committee to monitor corrective actions for identified findings and report on the sustainability of improvements, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director develops and implements a plan to repair and maintain facility walls, floors, and ceilings, and keep clean and dirty items separate, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director implements measures to monitor medication room temperature and humidity in the intensive care unit and community living center, in accordance with Veterans Health Administration Directive 1108.07(2), General Pharmacy Service Requirements.

The Director takes appropriate action so leaders update their local policy and develop service-level workflows for test result communications, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions to strengthen staff accountability for maintaining clean and safe patient care areas as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions so staff validate and document airflow testing in supply rooms annually as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate actions so staff conduct a risk assessment to identify areas that require temperature and humidity monitoring and implement changes as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations and Veterans Health Administration Directive 1108.07(2), General Pharmacy Service Requirements.

The Director implements controls so staff repair or replace malfunctioning fire doors to ensure proper closure during emergencies as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

The Director implements measures so staff conduct all required fire safety inspections and document the results as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

The Director takes appropriate actions to implement measures to test sprinkler systems as required by the National Fire Protection Association’s Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, NFPA 25.

The Director takes appropriate actions so staff evaluate processes to prevent repeat environment of care findings and take actions as warranted.

The Veterans Integrated Service Network Director monitors for similar or repeat environment of care findings and takes appropriate actions so facility leaders develop and implement facility-wide corrective action plans and sustain improvements.

The Director takes appropriate actions so each service chief develops a workflow that describes staff members’ roles in the process of communicating test results to providers and patients as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so staff track root cause analysis–driven improvement actions through to completion, monitor outcome measures, and implement processes to sustain improvements to comply with Veterans Health Administration National Center for Patient Safety’s Guide to Performing Root Cause Analysis.

The Chief of Staff takes appropriate action for evaluation and improvement of processes to identify adverse events that warrant institutional disclosures to patients or their representatives as required by Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients.

The Director takes appropriate actions to have staff safeguard patients’ protected health information, as required by Veterans Health Administration Directive 1605.01, Privacy and Release of Information.

The Director takes appropriate actions to have staff maintain a clean environment, consistent with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions to have staff maintain clean food and medication refrigerators, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Chief of Staff and Associate Director for Patient Care Services monitor performance data for test result communication, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

Establish mechanisms to make sure business cases are developed, promptly reviewed, and approved as required by the Office of Management and Budget Circular A‑11 and VA Directive 0011.

Perform periodic reviews to verify that business cases comply with Office of Management and Budget Circular A‑11 requirements by being updated throughout a project’s life cycle to reflect changes in scope, schedule, and cost, and to verify that if changes exceed 10 percent of the initially approved business case, they are reported to the Office of Management and Budget.

Verify that milestones for the Louisville new medical center project are updated to incorporate critical user-requested changes and that these changes are completed in a timely manner to prevent further delays, while keeping the project within its authorized scope, cost, and schedule.

Establish controls to ensure the executive director of the Office of Construction and Facilities Management fulfills the responsibilities in VA Directive 0067 to incorporate National Environmental Policy Act analysis early on in all land acquisition, planning, design, and construction projects.

Conduct a comprehensive review of major construction project obligations to ensure all costs related to each project, including those recorded in separate funding lines, are included in the total estimated project costs reported to Congress, consistent with 38 U.S.C. § 8120, 31 U.S.C. § 1105, Office of Management and Budget Circular A‑11, and volume 8 of VA Financial Policy.

Update the responsibilities section of VA Directive 0067 to reflect the expectation that, before budget authorization, major construction projects must proactively identify advance planning fund requirements to support the initiation of NEPA environmental reviews during project development.

Provide the VA Office of Inspector General with an implementation schedule for an acquisition framework to enable monitoring of major construction project performance.

Assess options to expand and optimize automation tools, including artificial intelligence–based solutions, for request for services processing to reduce manual steps and promote efficiency.

Address system limitations that prevent identification of whether actions specific to requests for services have been taken or are pending, such as the delegated clinician review.

Review and update national standard operating procedures for request for services processing to clarify roles and responsibilities, address inappropriate practices, and reduce processing delays.

Develop processes or controls to help improve the accuracy and consistency of the use of the actual receipt date as the official date the Veterans Health Administration received the request for services to maintain accurate timeliness tracking.

Make sure facilities provide accurate notifications to community providers and notify veterans at key processing stages.

Implement mechanisms to provide routine oversight of the request for services process, including assessing data accuracy and the timeliness of request processing, to reinforce accountability and support corrective action.

The Medical Center Director takes appropriate action so emergency department and dental clinic staff maintain a clean and safe environment and repair or replace damaged items to support effective disinfection, as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Medical Center Director takes appropriate action so emergency department staff establish and maintain an environment that protects patients’ privacy, as required by the Joint Commission standard, Rights and Responsibilities of the Individual 01.01.01.

The Medical Center Director takes appropriate action so all services develop workflows in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients, including defining responsibilities of non-provider personnel for communicating test results to patients.

The Director installs detectable warning surfaces at all walkways that transition to roadways, in accordance with VA’s PG-18-10, Site Design Manual.

The Associate Chief of Staff, Mental Health develops and implements written processes to ensure treatment planning on the inpatient mental health unit aligns with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service requirements. 

The Associate Chief of Staff, Mental Health requires a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit, in alignment with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Facility Director ensures implementation of a recovery-oriented environment on the inpatient mental health unit, consistent with Veterans Health Administration’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements a written standard operating procedure for the use of video monitoring on the inpatient mental health unit, as required by Veterans Health Administration Office of Mental Health Standard Operating Procedure 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06.”

The Chief of Staff ensures that only healthcare staff have access to video monitoring in treatment areas and that video equipment is used for monitoring, not recording, in accordance with Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

The Facility Director posts signage to notify veterans of video monitoring on the inpatient mental health unit, as required Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements in Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Staff requires documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administrationand develops a plan to monitor for sustained compliance, in accordance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures.

The Chief of Staff ensures discharge instructions include appointment locations in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”

The Facility Director requires all Interdisciplinary Safety Inspection Team members attend biannual inspections and record attendance consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.  

The Facility Director directs the Interdisciplinary Safety Inspection Team to provide biannual inspection attendance to the Comprehensive Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

The Facility Director ensures staff complete appeals within the required time frame in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.1, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Inspections and Appeals Under VHA [Veterans Health Administration] Directive 1167.”

The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

Improve vulnerability management processes so that all vulnerabilities are identified and mitigated; for vulnerabilities that cannot be mitigated by VA deadlines, create plans of action and milestones.

Improve the baseline configuration process to make sure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.

Confirm appropriate network isolation and protections for all medical devices and special‑purpose systems hosted on the Lovell Federal Healthcare System networks.

Separate the duties of maintaining physical blank key stock and making keys to improve physical access controls over key inventories.

Improve the process for monitoring and servicing uninterruptible power supplies that support the network infrastructure.

Complete the installation of grounding measures for all communications closets.

Establish a process to make sure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.